The Psychology of Addiction

Interviewer: I think most of us at one time or another may have joked that, "We're addicted to chocolate," or, "I'm addicted to that TV show," but those addictions aren't real addictions. We're going to examine addictions next on The Scope.

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Interviewer: Dr. Elizabeth Howell is with the University of Utah Hospital. Let's talk about addiction for a second. Now everybody jokes about, "I'm addicted to chocolate." That's not really addiction, is it?

Dr. Howell: Not really. I mean, some of the same brain processes are involved, but chocolate doesn't usually cause people to lose their family and their house and their life. It's a compulsion maybe to eat chocolate . . .

Interviewer: Sure.

Dr. Howell: . . . but it's not something that's going to kill you.

Interviewer: So let's talk about true addictions. I was doing a little bit of reading, and it just really was strange to me that if somebody is truly addicted, they can't look out for their own well being, they can't make decent decisions, because a lot of times people, you'll hear them say, "Well, wow, why didn't they just make a better choice than doing drugs?" But they really don't have that ability, if I understand correctly. Is that accurate?

Dr. Howell: Well, yeah. You have some choices about some things, but I think the main thing to remember is that when you're actively addicted, and you're using drugs or alcohol or both, that your brain is not working right. I mean, it's not the same as having a brain that is sort of firing on all cylinders at the same time.

Interviewer: Yeah. Is it the actual addiction, or is it the drugs, or a combination of both?

Dr. Howell: Both, really.

Interviewer: All right.

Dr. Howell: So the drugs actually, they alter how you perceive the world and how you see things, but they also do something that's very important, which is they activate the process in the brain, which is the addiction process, that really distorts how people think. So in Pennsylvania, there's kind of an epidemic of people mixing fentanyl, which is a very potent opioid, with heroin, and a lot of overdose deaths have happened because of that. And if you're someone in the public, you'll say, "Wow, that's really scary. If I were a heroin addict, I wouldn't be using anything right now . . .

Interviewer: Yeah, sure.

Dr. Howell: . . . because I'd be afraid I'd kill myself."

Interviewer: Yeah.

Dr. Howell: But if you're a real active addict, what you think is, "How did they get the good stuff?"

Interviewer: Really, that's the thought process?

Dr. Howell: That is the thought process.

Interviewer: And they want that.

Dr. Howell: And they want that, because they want something that is so good that it might kill them, and that is the insanity, as they say in the 12-step programs, of the addiction. The insanity of the disease is that your thinking is very distorted.

Interviewer: And that's how they frame in the head, "I want something so good it'll kill me?"

Dr. Howell: Well, it could be, yeah.

Interviewer: Wow.

Dr. Howell: You could get to that point.

Interviewer: So inside the brain, let's say somebody just has an addiction, but they're not currently using.

Dr. Howell: Right.

Interviewer: Is their brain a little different than somebody without that predisposition towards an addiction?

Dr. Howell: There are probably some differences in the brains of people before they ever start using. In the twin studies that have been done using alcoholic families, and alcohol is the easiest thing to study compared to other drugs, if a child was born to an alcoholic father and adopted into a non-alcoholic home, they still had a much higher risk of becoming alcoholic. The highest risk was a child of an alcoholic biological father adopted into an alcoholic home. So the nurture part, the environment, did play a certain role, but by far the biggest risk for addiction is genetic.

Interviewer: Does the brain physically get rewired because of addiction?

Dr. Howell: I don't know if it gets completely rewired, but there are certain genes that are turned on or off, depending on the different genes, when you start using.

Interviewer: Okay.

Dr. Howell: And, like you say, they're kind of laying there dormant.

Interviewer: Sure.

Dr. Howell: It's like a room with the lights off, but when you turn the lights on . . .

Interviewer: By taking a drink or doing a drug.

Dr. Howell: . . . right, then certain genes could be turned on or turned off. And the way that this happens, it's not like the first time you ever use that all the changes that happen, by the time you've been using for 20 years, are there. They happen over a period of time and in sort of wave of different changes in the brain, different parts of the brain, different systems of the brain, and it's quite complicated. I don't know if you would call it rewiring, but it's definitely a re-engineering of the brain.

Interviewer: So we've talked a lot about addiction. I want to talk for a moment now, and kind of wrap this up with, if somebody is a loved one of somebody who is addicted, help them be in the mindset of the addicted person so they can better help them.

Dr. Howell: I would try to imagine it as thinking of something that you feel like you have to have for life, like it's something that you need to survive. And when you're in the throes of addiction, the person who's addicted really feels as if that is the most important thing in life, that it is actually more important than food, or their children, or whatever, and that the drive to use is so strong that their behavior seems insane, because it is. Because what you can't control is the craving and the mental obsession and the compulsion. Now people obviously get into recovery, and they stop using, so we could get into this is it really a disease, can you really control it sort of debate, but what you can't control is what your brain is telling you. That's like saying if you're diabetic, I will not let my blood sugar go up.

Interviewer: Yeah.

Dr. Howell: You can do as much as you possibly can to keep your blood sugar from going up, but you can't always control that, because that's a physiologic process that is independent. And that's what the addiction is. Once it gets started, it's an independent physiologic process that can be managed, but it can't be just gotten rid of or controlled.

Interviewer: Or cured.

Dr. Howell: Or cured, yeah.

Interviewer: It's always there.

Dr. Howell: Right.

Interviewer: So what could somebody do to help that person? Because I don't think this is a do-it-yourself sort of a thing.

Dr. Howell: No, not really. And what we tell family members first is get informed and find out what you need to know about addiction and take care of yourself, because many times a person comes in for addiction treatment, their family has been trying to help them, but they've been doing it sort of in a backwards way. They're well-meaning, but they've been kind of enabling the person. They've been covering up for them. They've been bailing them out of jail. They've been doing this and that. And so you don't want to do that.
People need to experience the consequences of their addiction, and sometimes it's the only thing that will wake them up, because your brain is all changed, it's not working right, and you need a big wake-up call, and sometimes that needs to be letting people "hit bottom." Where you don't want somebody to hit bottom is if they're in danger of dying and hitting bottom, but if they're going to go to jail, or whatever, then I would let that play out, and then have a plan that, "Okay, we'll help you get out of jail," if that's what's happening, "if you will go to treatment."
There are some medications that can help, although we don't have enough, and then there are also many psychological, psychosocial treatments that include psychotherapy and changing behavior, more behavioral therapy, going to 12-step meetings, or some kind of support group.
The other thing you have to make sure of is that anything else that is involved that may be impacting the addiction is being treated. So if someone's depressed, they have post-traumatic stress disorder, or they're bipolar, or whatever, some sort of mental illness or mental disorder gets treated appropriately without addicting medications.

Interviewer: Yeah.

Dr. Howell: Yeah, because that's where I see a lot of people getting into trouble, is they have anxiety, so they're put on something else, like a benzodiazepine that's addicting, like Xanax or one of the others, and that's only going to make the problem worse. And the other thing that you need to do is make sure that besides that you're treating the psychiatric or mental problems, that you're also treating any physical problems that are going on. Somebody could have hyperthyroidism or something that could be triggering them to drink.

Interviewer: Sure.

Dr. Howell: I mean, there are a number of things. So the physical and the mental you want to take care of, and make sure that whatever treatment program you're looking at has the ability to check for those things and treat them, if appropriate.

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